Provider Demographics
NPI:1447245436
Name:KELLY, KAREN RAE (MSN)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:RAE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:MRS
Other - First Name:KAREN
Other - Middle Name:RAE
Other - Last Name:JERRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1520 FRIENDSHIP DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-4428
Mailing Address - Country:US
Mailing Address - Phone:317-888-1115
Mailing Address - Fax:
Practice Address - Street 1:9805 GEIST CROSSING DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4819
Practice Address - Country:US
Practice Address - Phone:612-659-7111
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28072059A363LF0000X
IN71000355B363LF0000X
IN71000355A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S66805Medicare UPIN